Form B-A-2 - Application For Cigarette Distributor'S License And Tobacco Products (Other Than Cigarettes) Or Update To An Existing Application
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1
2B-A-2
Application for Cigarette Distributor’s License and
Web
Tobacco Products (Other Than Cigarettes) or
7-11
Update to an Existing Application
North Carolina Department of Revenue
1. Federal Employer ID No.:
or Sole Proprietor’s Social Security No.:
2. Type of Entity
Sole Proprietorship
Fiduciary
Partnership
LLP
Corporation
LLC
Other
(Check One):
If N.C. Corporation, enter N.C. Secretary of State ID No.:
If a corporation, state of incorporation:
3. Legal Business or Owner’s Name:
4. Trade Name (DBA Name):
5. Name of Contact Person:
Telephone:
Fax:
Street
6. Business Location:
(Not P.O. Box Number)
State
City
Zip Code
County
7. Mailing Address:
Street or P.O. Box
State
City
Zip Code
County
8. Applicant is:
Resident
Nonresident
Manufacturer
Integrated Wholesaler
(Check One)
9. Type of Cigarette License Applied For:
Original Cigarette Distributor
Update to the Original License
(Check One)
10. Type of Other Tobacco Products License Applied For:
(Check One)
Original OTP Wholesale Dealer
Update to the Original Wholesale Dealer
Original OTP Retail Dealer
Update to the Original Retail Dealer
Fiscal (Please attach a calendar indicating the fiscal period beginning and ending dates for the year.)
11. Reporting Periods:
Traditional
12. Number of retail locations (Attach a list if more than one):
Beginning date of tobacco sales in N.C.:
(President, Vice President, Secretary, Treasurer, Chief Financial Officer, Manager, Primary Partners, Other Officers, etc.)
13. List Responsible Persons
:
Date of Birth
Resident Address
Title
Social Security No.
Name
14. Have any of the individuals listed on Line 13 ever been convicted of a felony or misdemeanor other than a minor traffic offense?
(Check One)
Yes
No
If yes, attach an explanation to this application.
15. Person responsible for filing cigarette and/or OTP excise tax returns and location of books and records during business hours:
Telephone Number
Name
Street
State
City
Zip Code
County
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